HQP-PFF-039
FOR Pag-IBIG Fund USE ONLY
MEMBERS DATA
FORM (MDF)
Pag-IBIG MID NUMBER
REGISTRATION TRACKING NUMBER
916047217598
INSTRUCTIONS
1. Accomplish this form in one (1) copy only. If registration is thru online, the
form should be printed back to back on one single sheet of paper.
2. Type or print all entries in BLOCK or CAPITAL LETTERS.
3. All fields which are marked with asterisk (*) are mandatory.
4. On the OCCUPATIONAL STATUS portion, if without employment or purpose
is pre-employment or never been employed, select UNEMPLOYED/NOT YET
EMPLOYED.
5. The NAME EXTENSION shall refer to JR., II, III and the like.
6. Indicate the full name of your FATHER and MOTHER as they appear in your
birth certificate.
*OCCUPATIONAL STATUS
EMPLOYED
7. On the OCCUPATION portion, indicate occupation based on the List of
Occupation, as provided in the Philippine Standard Occupational Classification
(PSOC).
8. On the HEIRS portion, the provision on the Laws on Succession, as provided
in the New Civil Code of the Philippines, as amended by the New Family Code,
shall be observed.
9. For any subsequent change of information, please secure and accomplish
Members Change of Information Form (MCIF, HQP-PFF-049) and submit to
the concerned Pag-IBIG Branch.
UNEMPLOYED/ NOT YET EMPLOYED
*MEMBERSHIP CATEGORY
MANDATORY
EMPLOYED PRIVATE
EMPLOYED GOVERNMENT
OVERSEAS FILIPINO WORKER (OFW)
SELF-EMPLOYED (SE)
PENSIONER/INVESTOR/LESSOR
OTHERS
Please specify ________________
VOLUNTARY
EMPLOYED
EMPLOYED FOREIGN GOVERNMENT
BARANGAY OFFICIAL/EMPLOYEE
INDIVIDUAL PAYOR (IP)
NON-WORKING SPOUSE
MEMBER OF RELIGIOUS GROUP
MEMBER OF COOPERATIVE/TRADE UNION
NAME
EXTENSION
FIRST NAME
LAST NAME
NO MIDDLE NAME
MIDDLE NAME
(check if applicable only)
(e.g. Jr., II)
*MEMBER
BALAS
WILGIN
DAMILES
FATHER
BALAS
WILSON
MALIN
DAMILES
GINA
LAURIE
BALAS
WILGIN
DAMILES
*MOTHER (Maiden Name)
*SPOUSE (If Married)
MEMBERS NAME AS
APPEARING IN THE BIRTH
CERTIFICATE
*DATE OF BIRTH
0
*MARITAL STATUS
Single/Unmarried
Married
mm dd yyyy
TAXPAYER IDENTIFICATION NUMBER (TIN)
Widow/er
Legally Separated
Annulled
SSS/GSIS NUMBER
*PLACE OF BIRTH (City/Municipality/Province/Country) *CITIZENSHIP
(Please indicate country if born outside the Philippines)
SERGIO OSMEA, ZAMBOANGA DEL NORTE
HEIGHT
WEIGHT
*SEX
Male
160 (cm)
57 (kg)
______
______
Female
COMMON REFERENCE NUMBER (CRN)
(If Available)
FILIPINO
PROMINENT DISTINGUISHING FACIAL FEATURES
EMPLOYEE NUMBER
(Ex. Moles, Scars, etc.)
For AFP/PNP Employee, Serial/Badge No.
FREQUENCY OF MEMBERSHIP SAVINGS (MS)
PAYMENT (If payment of MS is not thru payroll deduction)
Monthly
Quarterly
For DepEd Employee, Division Code-Station Code
Semi-Annually
Annually
ADDRESS AND CONTACT DETAILS
*PERMANENT HOME ADDRESS
Unit/Room No., Floor
Building Name
Lot No., Block No., Phase No. House No
Street Name
Subdivision
PUROK RIVERSIDE
Barangay
OLINGAN
Municipality/City
DIPOLOG CITY
Province/State/Country(if abroad)
ZAMBOANGA DEL NORTE
7100
Cell Phone
0930
Unit/Room No., Floor
Building Name
Barangay
Municipality/City
Lot No., Block No., Phase No. House No
Street Name
Subdivision
PUROK RIVERSIDE
DIPOLOG CITY
Province/State/Country(if abroad)
7488953
Business (Direct Line)
ZIP Code
Business (Trunk Line)
ZAMBOANGA DEL NORTE
Local
7100
*PREFERRED MAILING ADDRESS
Present Home Address
Home
ZIP Code
*PRESENT HOME ADDRESS
OLINGAN
(Indicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NUMBER
Email Address
Permanent Home Address
Employer/Business Address
THIS FORM MAY BE REPRODUCED. NOT FOR SALE.
wilgin_balas@yahoo.com
(Rev. 03.1, 01/2015)
PRESENT EMPLOYMENT DETAILS (If with more than one (1) employer, use separate sheet and follow format below)
*EMPLOYER/BUSINESS NAME
MONTHLY INCOME
Basic
X FACTOR CONTRACTORS AND GENERAL SERVICES
Building Name
Lot No., Block No., Phase No. House No.
KHUZNS PLACE BACK BLDG
Street Name
Barangay
NORTHROAD
Province
*State/Country (If abroad)
7,280.00
Land-based (Pls. specify country of assignment)
_____________________________
Sea-based (Pls. specify manning agency)
_____________________________
OFFICE ASSIGNMENT
DIPOLOG CITY
ZIP Code
6014
CEBU
*OCCUPATION
*TYPE OF WORK (For OFWs only)
ESTANCIA
MANDAUE CITY
0.00
Total Mo. Income
Subdivision
Municipality/City
Allowances/Others
*EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor
7,280.00
*EMPLOYMENT STATUS
MODELS, DEMONSTRATORS, AND
PRODUCT PROMOTERS
Permanent/Regular
Casual
Branch ____________
Head Office
*DATE EMPLOYED (Month, Year)
Contractual
Project-based
Part-time/Temporary
April 2015
PREVIOUS EMPLOYMENT FROM DATE OF Pag-IBIG Fund MEMBERSHIP (Use another sheet if necessary)
EMPLOYER/BUSINESS NAME
OFFICE ASSIGNMENT
Head Office
Branch ____________
EMPLOYER/BUSINESS ADDRESS
FROM
EMPLOYER/BUSINESS NAME
OFFICE ASSIGNMENT
EMPLOYER/BUSINESS ADDRESS
FROM
EMPLOYER/BUSINESS NAME
OFFICE ASSIGNMENT
TO
y
Head Office
Branch ____________
Branch ____________
TO
FROM
m
TO
Head Office
EMPLOYER/BUSINESS ADDRESS
HEIRS (In case of death, Fund benefits shall be divided among the members heirs in accordance with the New Civil Code as amended by the New Family Code) (Use another sheet if necessary)
LAST NAME
BALAS
BALAS
BALAS
FIRST NAME
WILSON
GINA
NAME
EXTENSION
MIDDLE NAME
NO MIDDLE NAME
(Check only if applicable)
RELATIONSHIP
FATHER
MALIN
MOTHER
DAMILES
SON
MAC DYNNIEL
DATE OF BIRTH
1 2
0 3
9 7 2
0 1
2 0
9 7 5
0 7
0 8
0 1 2
I HEREBY CERTIFY THAT THE INFORMATION GIVEN AND ALL STATEMENTS MADE HEREIN ARE TRUE AND CORRECT.
_________________________________
02/16/2016
_________________
SIGNATURE OF MEMBER
DATE
FOR Pag-IBIG FUND USE ONLY
RECEIVED BY
DATE
DISCLAIMER: Membership registration with the Fund does not automatically qualify a Pag-IBIG member to avail of the Funds various loan
programs. A Pag-IBIG member must satisfy the eligibility requirements and comply with the documentary requirements, which is
subject to verification and approval.
